Screening, Brief Intervention, and Referral to Treatment Core Curriculum

Transcription

1 Screening, Brief Intervention, and Referral to Treatment Core Curriculum Dr. Maite Mena, PsyD School of Education and Human Development, University of Miami Funded by the Health Foundation of Little Havana

2 What Is SBIRT and Why Use It?

3 At Risk Alcohol Brief Intervention Video Presentation

4 Traditional Response to Substance Use Universal prevention strategies. Specialized treatment services. Gap in service systems for at-risk populations.

5 SBIRT: A Public Health Solution: Substance abuse leads to significant medical, social, legal, financial consequences. Excessive drinking, illicit drug use, and prescription drug misuse are often undiagnosed by medical professionals. Treatment GAP Why SBIRT? The brief intervention itself is inherently valuable, and positive screens may not require referral to specialty treatment. Early, brief interventions are clinically effective and costefficient.

6 Goal of SBIRT Identify and intervene early with those who are at moderate or high risk for psychosocial or health problems related to their substance use.

7 What is SBIRT? Intervention based on Motivational Interviewing (MI). 3 Components: SCREENING BRIEF INTERVENTION REFERRAL TO TREATMENT

8 Question? Why might I choose to support SBIRT implementation?

9 Questions you may be asking Q: Do I really have to do this thing? Q: How much hassle is involved? Q: Will it annoy my patients?

10 Patients Are Open To Discussing Their Substance Use To Help Their Health Survey on Patient Attitudes Primary Care 1 Women s Health 2 Agree/Strongly Agree Agree/Strongly Agree If my doctor asked me how much I drink, I would give an honest answer. If my drinking is affecting my health, my doctor should advise me to cut down on alcohol. As part of my medical care, my doctor should feel free to ask me how much alcohol I drink. I would be annoyed if my doctor asked me how much alcohol I drink. I would be embarrassed if my doctor asked me how much alcohol I drink. 92% 92% 96% 93% 93% 81% Disagree/Strongly Disagree Disagree/Strongly Disagree 86% 82% 78% 83% Source: 1. Miller, P. M., et al. (2006). Alcohol & Alcoholism.; 2. Hettema et al. (2015). Journal of Women s Health. Adapted from The Oregon SBIRT Primary Care Residency Initiative training curriculum (

11 SBIRT Is a Highly Flexible Intervention SBIRT Settings Aging/Senior Services Behavioral Health Clinic Community Health Center Community Mental Health Center Drug Abuse/Addiction Services Emergency Room Federally Qualified Health Center Homeless Facility Hospital Inpatient Primary Care Clinic Psychiatric Clinic School-Based/Student Health Trauma Centers/Trauma Units Urgent Care Veterans Hospital Other Agency Sites

12 Why is SBIRT Important Unhealthy Substance use is a major preventable public health problem. One in six Americans binge drinks four times per month- MOST not dependent (CDC, January 2012) More than 100,000 deaths. More than $ 600 billion in costs to society. Ripple effect

13 Unfortunately, these kinds of experiences remain too commonplace

14 Based on estimates from a national survey 1, in 2014, there are 22.7 million people that meet criteria for a substance use disorder. Of these people... 11% 2.5 million received substance use treatment 20.2 million people did not receive treatment 89% Source: 1: (Figure created with data from:) Substance Abuse and Mental Health Services Administration. (2014). The NSDUH Report.

15 2013: Alcohol use in the past month

16 Medical and Psychiatric Harm of High-Risk Drinking Aggressive, irrational behavior. Arguments. Violence. Depression. Nervousness Cancer of throat and mouth. Frequent colds. Reduced infection resistance. Increased pneumonia risk. Liver damage. Trembling hands, trembling fingers. Numbness. Ulcer. Impaired sensation leading to falls.

17 Medical and Psychiatric Harm of High-Risk Drinking (continued) Numb, tingling toes. Alcohol dependence. Memory loss. Premature aging. Drinker s nose. Weakness of heart muscle. Heart failure. Anemia. Impaired blood clotting. Breast cancer. Vitamin deficiency. Bleeding. Severe stomach inflammation. Vomiting. Diarrhea. Malnutrition. Inflammation of the pancreas. Impaired sexual performance. Risk of giving birth to deformed babies or low birth weight babies.

18 Research Shows Brief interventions ARE Low cost and effective Among those with less severe problems Brief interventions are feasible and highly effective components of an overall public health approach to reducing alcohol misuse. (Whitlock et al., 2004, for U.S. Preventive Services Task Force)

19 Making a Measurable Difference Since 2003, SAMHSA has supported SBIRT programs, with more than 1.5 million persons screened. 1 Outcome data confirm a 40 percent reduction in harmful use of alcohol by those drinking at risky levels and a 55 percent reduction in negative social consequences. 2 Outcome data also demonstrate positive benefits for reduced illicit substance use. 2 Source: 1. Madras. (2010) Annals of the New York Academy of Sciences.; 2. United States Department of Health and Human Services. (2011).

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21 Screening universally allows you to: Detect health problems related to at-risk alcohol and substance use at an early stage. Detect alcohol and substance use patterns that can increase future injury or illness risks. Intervene and educate about at-risk alcohol and other substance use. People are more open to change than you might expect.

22 Screening Strategy Binge Prescreening Alcohol Drugs Chronic

23 25% of Prescreenings are Positive

24 Alcohol Prescreening Do you sometimes drink beer, wine, or other alcoholic beverages? NO YES NIAAA Single Screener Weekly Average Source: Smith, P. C., Schmidt, S. M., Allensworth-Davies, D., & Saitz, R. (2009). Primary care validation of a single-question alcohol screening test. J Gen Intern Med 24(7),

25 NIAAA Single Screener How many times in the past year have you had X drinks or more in a day? X = 4 if woman or man over age 65 X = 5 if man under age 65 If the answer is one or more, move on to full screen. Sensitivity/Specificity: 82%/79%

26 Weekly Average On average, how many days a week do you have an alcoholic drink? On a typical drinking day, how many drinks do you have? (Daily average) Weekly average = days X drinks Recommended Limits Men = 2 per day/14 per week Women/anyone 65+ = 1 per day or 7 drinks per week > Regular limits = at-risk drinker

27 Any Positive Prescreening: Go to full Screen Binge drink ( 5 for men or 4 for women/anyone 65+) Or patient exceeds regular limits? (Men: 2/day or 14/week Women/anyone 65+: 1/day or 7/week) NO Patient is at low risk. YES Patient could be at risk. Screen for maladaptive pattern of use and clinically significant alcohol impairment using AUDIT.

28 When Screening, It s Useful To Clarify What One Drink Is!

29 How Much Is One Drink? 5-oz glass of wine (5 glasses in one bottle) 12-oz glass of beer (one can) 1.5-oz spirits 80-proof 1 jigger Equivalent to 14 grams pure alcohol

30 Screening: AUDIT Alcohol Use Disorders Identification Test Developed by World Health Organization (WHO) Ten questions, self-administered or through an interview. Addresses: Recent alcohol use, alcohol dependence symptoms, and alcohol-related problems

31 AUDIT Domain WHO, 1992

32 Scoring the AUDIT Dependent Use (20+) Harmful Use (16 19) At-Risk Use (8 15) Low Risk (0 7)

33 Prescreening for Drugs How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons? For instance because of the feeling it caused If response is, None, screening is complete. If response contains suspicious clues, inquire further. Sensitivity/Specificity: 100%/74% Source: Smith, P. C., Schmidt, S. M., Allensworth-Davies, D., & Saitz, R. (2010). A single-question screening test for drug use in primary care. Arch Intern Med,170(13),

34 A Positive Prescreen The followup questions are to assess impact and whether substance use is serious enough to warrant a substance use disorder diagnosis Ask which drugs the patient has been using, such as cocaine, meth, heroin, ecstasy, marijuana, opioids, etc. Determine frequency and quantity. Ask about negative impacts.

35 Drug Abuse Screening Test. DAST (10) Shortened version of DAST 28 Developed by Addiction Research Foundation, now the Center for Addiction and Mental Health Yields a quantitative index of problems related to drug misuse Strengths Sensitive screening tool for at-risk drug use Weaknesses Does not include alcohol use

36 DAST(10) Questionnaire Source: Yudko et al., 2007

37 DAST(10) Interpretation Yudko et al., 2007

38 Scoring the DAST(10) High Risk (6+) Harmful Use (3 5) Hazardous Use (1 2) Abstainers (0)

39 Key Points for Screening Prescreening is usually part of another health and wellness survey. Prescreen everyone. Use a validated tool. Ask about both alcohol and drug use Explore each substance. Follow up positives or "red flags" by assessing details and consequences of use. Use your MI skills and show nonjudgmental, empathic verbal and nonverbal behaviors during screening.

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41 How to help people change: The wrong approach

42 Definition of Motivational Interviewing Motivational interviewing is a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.

43 Motivational Interviewing Spirit Principles Steps Skills Brief Intervention using MI

44 Motivational Interviewing Spirit

45 Spirit of MI A way of being with patients that is Collaborative Evocative Respectful of autonomy

46 Collaboration No confrontation Developing a partnership with the patient Fostering and encouraging power sharing in the interaction

47 Evocation No Education Motivation for change resides within the patient. Drawing on the patient s own perceptions, experiences, and goals.

48 Respect Autonomy Not Authority Patient s right to choose. Emphasize patient control and choice. The patient is responsible for the outcomes.

49 Motivational Interviewing Principles

50 EE: Express empathy. DD: Develop discrepancy. RR: Roll with resistance. SS: Support self-efficacy. MI Principles Reference: Miller, W. R., Zweben, A., DiClemente, C. C., & Rychtarik, R. G. (1992). Motivational enhancement therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism.

51 Four Tasks of the MI Process Engage Would you mind if we take a few minutes to review the results of your health and wellness survey? Focus- Focus on understanding what your patient is saying and how they feel. Focus by reflecting, summarizing and developing discrepancies. Evoke- Evoke a personal meaning (thoughts, feelings, motivation) from patient to enhance personal motivation for change. Plan- Raise the subject of a plan, support selfefficacy and autonomy, and address elements of a change plan.

52 Engage Express empathy Ask questions Use affirmations Support autonomy

53 Focus Directive Reflecting Summarizing Developing discrepancies

54 Evoke Motivation Concerns

55 Plan Support selfefficacy Realistic Address elements of change

56 Motivational Interviewing Core skills

57 MI Skills Open-ended questions Affirmations Reflections Summaries

58 Open-Ended Questions Require more of a response than a simple yes/no Often start with words such as How What Tell me about Usually go from general to specific

59 Open-Ended Questions The patient conveys more information Encourages engagement Opens the door for exploration of ambivalence

60 Closed-Ended Questions: Conversational Dead Ends Are for gathering very specific information Tend to solicit yes-or-no answers Convey impression that the agenda is not focused on the patient

61 Affirmations Compliments Statements of appreciation and understanding Praise positive behaviors Support the person as they describe difficult situations

62 Why affirm? Promote self-efficacy, Prevent discouragement Build rapport Reinforce open exploration (patient talk) Caveat Must be done sincerely

63 Affirmations May Include: Commenting positively on an attribute You are determined to get your health back. A statement of appreciation I appreciate your efforts despite the discomfort you re in. A compliment Thank you for all your hard work today.

64 Reflective Listening One of the hardest skills to learn. Reflective listening is a way of checking rather than assuming that you know what is meant. (Miller and Rollnick, 2002)

65 Reflective Listening Involves listening and understanding the meaning of what the patient says Convey empathy

66 Why listen reflectively? Serves 2 purposes: Brings to life the principle of EXPRESS EMPATHY And

67 Why listen reflectively? Supports the goaldirected aspect of Motivational Interviewing

68 Levels of Reflections Simple: Repeat, Rephrase Complex: Paraphrase, Reflect Feeling Double-Sided: Both sides of Ambivalence

69 Simple Reflection Patient: I hear what you are saying about my drinking, but I don t think it s such a big deal. Clinician: So, at this moment you are not too concerned about your drinking. Patient: She is driving me crazy trying to get me to quit. Clinician: Her methods are really bothering you.

70 Simple Reflection: Amplify Patient: All my friends smoke weed and I don t see myself giving it up. Clinician: So, you re likely to keep smoking forever. Patient: I don t know why everybody is making such a big deal over my drinking. I don t drink that much. Clinician: There s no reason for any concern.

71 Complex Reflection: Paraphrase Patient: Who are you to be giving me advice? What do you know about drugs? You ve probably never even smoked a joint! Clinician: It s hard to imagine how I could possibly understand. Patient: I just don t want to take pills. I ought to be able to handle this on my own. Clinician: You don t want to rely on a drug. It seems to you like a crutch.

72 Complex Reflection: Feeling Patient: My wife decided not to come today. She says this is my problem, and I need to solve it or find a new wife. After all these years of my using around her, now she wants immediate change and doesn t want to help me! Clinician: Her choosing not to attend today s meeting was a big disappointment for you.

73 Double-Sided Reflections A double-sided reflection attempts to reflect back both sides of the ambivalence the patient experiences. Patient: But I can't quit smoking. I mean, all my friends smoke! Clinician: You can't imagine how you could not smoke with your friends, and at the same time you're worried about how it's affecting you. Patient: Yes. I guess I have mixed feelings.

74 Summaries Periodically summarize what has occurred in the counseling session. Summary usages Begin a session End a session Transition

75 Summaries (continued) Strategic summary select what information should be included and what can be minimized or left out. Additional information can also be incorporated into summaries for example, past conversations, assessment results, collateral reports, etc.

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77 Theoretical Framework Informing MI Prochaska and DiClemente identified five stages of change your patient can experience: 1. Precontemplation 2. Contemplation 3. Preparation 4. Action 5. Maintenance Prochaska & DiClemente (1984)

78 Remember Readiness to change State Trait

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80 Change Talk: DARN Desire I wish/want to Ability I can/could Reasons It s important because Need I have to

81 Affirm and reinforce change talk as it emerges. I hear you are quite concerned about the effects your drinking may be having on your family and that not being a good parent or partner is important for you.

82 Motivational Interviewing: Enhancing Motivation To Change Strategies

83 Linking Screening and Brief Intervention MI strategies facilitate Finding personal and compelling reasons to change Building readiness to change Making commitment to change

84 MI Strategies Most Commonly Used in Brief Intervention Decisional balance Readiness ruler Personalized reflective discussion

85 Highlights the ambivalence Decisional Balance Leverages the costs versus the benefits (start with the benefits)

86 Readiness Ruler On a scale of 1 to 10, how ready are you to make a change?

87 Brief Intervention

88 Review of SBIRT Do you recall the primary goal of SBIRT?

89 Goal of SBIRT Substance use continuum Abstinence Moderate use (lower risk use) At-risk use (higher risk use) Abuse Dependence Substance Use Disorders (SUDs)

90 What Is Brief Intervention? An awareness-raising intervention given to risky or problematic substance users. Types: Personalized Reflective Discussion Brief Negotiated Interview

91 Brief Negotiated Interview Semi structured interview based on MI. Proven evidence-based practice. Can be completed in 5 15 minutes. Developed by Gail D Onofrio, M.D., Ed Bernstein, M.D., Judith Bernstein, M.S.N., Ph.D., and Steven Rollnick, Ph.D. Special acknowledgement is made to Drs. Stephen Rollnick, Gail D Onofrio, and Ed Bernstein for granting permission to orient participants to the brief negotiated interview.

92 Steps in the BNI 1. Build rapport raise the subject. Explore the pros and cons of use. 2. Provide feedback. Provide screening results, relate to norms, get their reaction 3. Build readiness to change. Assess readiness, develop discrepancy, look for change 4. Negotiate a plan for change.

93 Raise the subject Start the discussion by asking permission of our patients to have the conversation. Example: Would it be all right with you to spend a few minutes discussing the results of the wellness survey you just completed?

94 Providing Feedback Substance use risk Based on your AUDIT screening You are here Low Moderate High Very High 0 40 Review Score Level of risk Risk behaviors Normative behavior

95 Evoking Personal Meaning Open-ended questions: From your perspective.. What relationship might there be between your drinking and? What are your concerns regarding use? What are the important reasons for you to choose to stop or decrease your use? What are the benefits you can see from stopping or cutting down?

96 Discuss the Pros and Cons of Use Help me understand through your eyes. 1. What are the good things about using alcohol? 2. What are some of the not-so-good things about using alcohol?

97 Discuss the Pros and Cons of Use Applying MI Decisional Balance Using reflections On one hand, you enjoy On the other hand, I hear your concern about

98 Summarizing Acknowledges the patient s perceived benefits of use Elicits the personal and important problems or concerns caused by use Elicits, affirms, and reinforces motivation to change Helps resolve ambivalence and reinforces motivation

99 Enhancing Motivation Readiness Ruler On a scale from 1 to 10, how ready are you to make a change to reduce your drinking?

100 Negotiating Commitment Simple Realistic Specific Attainable Follow-up time line Negotiating a PLAN

101 Motivational Interviewing/Brief Intervention-A better approach Video Presentation

102 Brief Therapy For moderate to high risk use of alcohol or drugs Motivational discussion; focused on empowerment and goal setting Includes assessment, education, problem-solving, coping strategies, supportive social environment Typically up to 12 sessions, each one approached as though it could be the last

103 Referral to Treatment Referral

104 About Patients Screened in Primary Care Evidence indicates that approximately 5 percent of patients screened will require a referral to either brief treatment or specialty treatment.

105 What Is Treatment? Treatment may include Counseling and other psychosocial rehabilitation services Medications Involvement with self-help (AA, NA, Al-Anon) Complementary wellness (diet, exercise, meditation)

106 Most patients can be successfully served in outpatient treatment. Referral Guidelines for Greatest Success Determine if patient is drug or alcohol dependent and needs medical detoxification (usually inpatient). A nondependent substance abuser is usually treated as an outpatient unless there are other risk factors.

107 Confirm your follow-up plan with A Strong Referral to Appropriate Treatment Provider Is Key When your patient is ready Make a plan with the patient. You or your staff should actively participate in the referral process. The warmer the referral handoff, the better the outcome. Decide how you will interact/communicate with the provider.

108 What Is a Warm-Handoff Referral? The clinician directly introduces the patient to the treatment provider at the time of the patient s medical visit. Reasons: Establish an initial direct contact between the patient and the treatment counselor and To confer the trust and rapport. Evidence strongly indicates that warm handoffs are dramatically more successful than passive referrals.

109 Plan for the Nuts and Bolts Whom do you call? Do you have access to referral resource information? What form do you fill out? What support staff can help?

110 Considerations When Choosing a Treatment Provider Language ability/cultural competence Family support Services that meet the patient s needs Record of keeping primary care provider informed of patient s progress and ongoing needs Accessible location/transportation

111 Payment for Services Does the provider accept your patient s insurance? Will the patient need to get prior insurance authorization? If the patient does not have insurance, does the provider offer services on a sliding-fee scale?

112 What Should You Expect? Programs change over time. Maintain an up-to-date roster of public and private treatment and selfhelp resources in your community.

113 Common Mistakes To Avoid Rushing into action and making a treatment referral when the patient isn t interested or ready Referring to a program that is full or does not take the patient s insurance Not knowing your referral base Not considering pharmacotherapy in support of treatment and recovery Seeing the patient as resistant or self-sabotaging instead of having a chronic disease

114 WHAT IF THE PERSON DOES NOT WANT A Encourage follow-up REFERRAL? At follow-up visit: Inquire about use Review goals and progress Reinforce and motivate

115 Thank you! Feel free to contact me at: